History and exam protocols and EHR customization play essential roles.
In ophthalmology, the chief complaint (CC) and patient history are critical components in guiding the physician through the diagnostic process. According to a study in the Journal of Current Ophthalmology, “one experienced senior attending physician was able to correctly diagnose a problem 88% of the time based on chief complaint and history, demonstrating the remarkable diagnostic value of patient history in clinical practice.”1
With this in mind, let’s explore the key elements of a patient history, the flexibility provided by the new evaluation and management (E/M) guidelines for patient workups and ways to leverage electronic health records (EHRs) for greater efficiency.
OFFICE VISIT KEY COMPONENTS
A patient history typically consists of three key components: the CC, supported by a relevant history of present illness (HPI); a comprehensive medical history; and a review of systems (ROS). According to Palmetto, a Medicare Administrative Contractor, a CC “is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the patient encounter. A CC is required for all levels of service.”2
Additionally, the Medicare Transmittal 1802 states the following:
“The coverage of services rendered by an ophthalmologist is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. When a beneficiary goes to an ophthalmologist with a complaint or symptoms of an eye disease or injury, the ophthalmologist’s services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her ophthalmologist for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition.”3
The patient’s medical history generally includes information on medications (both systemic and ocular), past surgeries, family and social history and any allergies. The ROS is an inventory of symptoms related to other organ systems the patient is experiencing, such as hearing loss, headache or cough. While obtaining a thorough history is essential for the initial patient visit, it may not be necessary at every subsequent encounter.
E/M CHANGES GIVE FLEXIBILITY
Before the major changes in 2021, the E/M guidelines were more complex, emphasizing a detailed patient history, physical examination and medical decision making to determine the level of service. Recognizing the burden this placed on physicians and their clinical staff, CMS collaborated with the American Medical Association to revise the “outdated” E/M process. The significant update in 2021 simplified the history and examination requirements, allowing the treating physician to determine the “nature and extent of the history and/or physical examination.”4 This change gives physicians greater flexibility and the opportunity to establish “medically appropriate”5 history and exam protocols, streamlining various types of patient encounters.
HISTORY AND EXAM REQUIREMENTS
In eye care, we have two different coding categories to choose from: E/M codes (99202–99215) and eye codes (9200X/9201X). Fortunately, many of the requirements for eye codes overlap with the “medically appropriate” history and exam elements needed for E/M code selection. The 2024 Current Procedural Terminology (CPT) Ophthalmological Services Guidelines require a “history” and “general medical observation” for both intermediate and comprehensive eye codes. As mentioned earlier, a CC is necessary to establish medical necessity for all exams. However, terms such as “history” and “general medical observation” are somewhat vague. By documenting key components such as patient medications, surgeries and ROS, the documentation can support both E/M and eye codes. This approach allows for the flexibility to choose the code that provides the highest reimbursement based on the documentation.
EXAM PROTOCOLS
The recent updates to the E/M codes were designed to simplify the process and reduce the burden on clinical personnel. This makes it an ideal time for eye-care practices to update or establish workup protocols. Different subspecialties often have follow-up encounters with specific intervals and expectations for the exam. For example, a glaucoma specialist might see a stable primary open-angle glaucoma patient quarterly to check intraocular pressure (IOP) and only require the technician to obtain information about compliance with their eyedrop regimen, visual acuity (VA) and IOP. Conversely, a comprehensive ophthalmologist might see a stable diabetic patient annually and expect a thorough history and full exam.
It’s important for practices to identify these patterns and implement efficient protocols to help clinical staff gather what is medically appropriate for the physician and specific encounter type. This prevents the physician from having to sift through unrelated or unnecessary documentation, negatively impacting operational efficiency.
OPTIMIZING EHR EFFICIENCIES
Many EHRs offer the option to customize templates based on specific exam types, subspecialties and by individual physicians. Developing different templates can ease the clinical burden and help technicians obtain only the information relevant to that exam. For instance, many EHRs can highlight different elements of the patient exam to alert the technician that they must be completed, with highlighted elements varying by exam type. Consultations and annual exams might highlight every history and exam element to ensure a thorough exam.
Conversely, a brief AMD check might only highlight the CC, medical history, VA, IOP and dilation, as these may be the medically appropriate elements for this encounter type.
While EHRs are useful for creating templates, they can also present challenges with features such as cloning or copy forward and the ability to mark everything as “normal” before the exam. The information gathered by the technician in the CC, history and exam significantly impacts the diagnostic outcome for the patient. If the chart is marked “normal” for everything and accidentally left unchanged when there is a CVF defect, the physician could be misled. This risk also applies to the CC. If information is copied from a previous encounter without being updated, it might cause the physician to spend extra time examining the patient and performing unnecessary tests to address issues that no longer exist.
Time is valuable, so ensuring the CC and patient history are accurate is crucial for streamlining the exam and maximizing the physician’s efficiency.
IN PRACTICE
The importance of complete and accurate patient histories and examinations in patient care cannot be overstated. With the revised E/M guidelines of 2021, we can now be more targeted in obtaining these essential details.
By investing effort into updating or establishing work-up protocols and customizing our EHR systems, we can create informative chart notes that enhance our physicians’ ability to deliver accurate and efficient patient care. OM
References
1. Journal of Current Ophthalmology. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277212/#:~:text=Remarkably%2C%2056%25%20of%20correct%20diagnoses,made%20by%20chief%20complaint%20alone. Accessed July 11, 2024.
2. E/M Weekly Tip: Chief Complaint. Palmetto GBA. https://www.palmettogba.com/palmetto/jmb.nsf/DIDC/8UYH6H3481~Evaluation%20and%20Management%20(EM)~Tips#:~:text=A%20chief%20complaint%20(CC)%20is,for%20all%20levels%20of%20service. Accessed July 11, 2024.
3. Medicare Carriers Manual Part 3 – Claims Process Transmittal 1802. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r1802b3.pdf. Accessed July 11, 2024.
4. CPT Evaluation and Management Code and Guideline Changes – 2023. American Medical Association. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf. Accessed July 11, 2024.
5. Medicare Learning Network Evaluation and Management Servies. Centers for Medicare & Medicaid Services. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf. Accessed July 11, 2024.
